Turkish Society of Radiology 2011

18
R
adiological practice includes classification of illnesses with similar
characteristics through recognizable signs. Knowledge of and abil-
ity to recognize these signs can aid the physician in shortening
the differential diagnosis list and deciding on the ultimate diagnosis for
a patient. In this report, 23 important and frequently seen radiological
signs are presented and described using chest X-rays, computed tomog-
raphy (CT) images, illustrations and photographs.
Plain films
Air bronchogram sign
Bronchi, which are not normally seen, become visible as a result of
opacification of the lung parenchyma. Branching, tubular lucencies of
bronchi are seen in an opacified lung (Fig. 1a). This sign shows that
the pathology is in the lung parenchyma itself (1). This sign is most
frequently encountered in pneumonia and pulmonary edema. Its gen-
eralized form can be seen in respiratory distress syndrome (2). The air
bronchogram sign shows that the central bronchi are not obstructed;
however, it can also be seen when a mass causes half-obstruction. Bron-
chioalveolar carcinoma, lymphoma, interstitial fibrosis, alveolar hemor-
rhage, fibrosis due to radiation and sarcoidosis can also present with this
sign (13). This sign can also be seen on CT images (Fig. 1b).
Silhouette sign
In a chest x-ray, non-visualization of the border of an anatomical
structure that is normally visualized shows that the area neighboring
this margin is filled with tissue or material of the same density (Fig. 2).
The silhouette sign is an important sign indicating the localization of a
lesion (4). A well-known example is obliteration of the right heart border
due to middle lobe atelectasis. This rule can also be applied to the arch of
the aorta, the hemidiaphragms and the left border of the heart.
A silhouette sign of the hila is called the hilum overlay sign. It is
used to determine the localization of a lesion in the hilar region in chest
X-rays. If hilar vessels can clearly be seen inside the lesion, the lesion
is either anterior or posterior to the hilus. If the hilar vessels cannot be
discriminated from the lesion, the lesion is at the hilus (Fig. 3) (57).
Deep sulcus sign
The deep sulcus sign describes the radiolucency extending from
the lateral costophrenic angle to the hypochondrium (Fig. 4). It is an
important clue indicating possible pneumothorax in chest x-rays ob-
tained in the supine position. When plain films are taken with the sub-
ject in an upright position, the free air in the pleural space gathers at
the apicolateral space. In the supine position, the air accumulating at
the anterior space forms a triangular radiolucency that makes the infe-
CHEST I MAGI NG
PI CTORI AL ESSAY
Signs in chest imaging
Oktay Algn, Gkhan Gkalp, Uur Topal
From the Department of Radiology (O.A. droktayalgin@gmail.
com), Uluda University School of Medicine, Bursa, Turkey.
Received 12 June 2009; revision requested 4 October 2009; revision
received 24 October 2009; accepted 1 November 2009.
Published online 28 July 2010
DOI 10.4261/1305-3825.DIR.2901-09.1
ABSTRACT
A radiological sign can sometimes resemble a particular object
or pattern and is often highly suggestive of a group of similar
pathologies. Awareness of such similarities can shorten the dif-
ferential diagnosis list. Many such signs have been described
for X-ray and computed tomography (CT) images. In this ar-
ticle, we present the most frequently encountered plain film
and CT signs in chest imaging. These signs include for plain
films the air bronchogram sign, silhouette sign, deep sulcus
sign, Continuous diaphragm sign, air crescent (meniscus)
sign, Golden S sign, cervicothoracic sign, Luftsichel sign, scim-
itar sign, doughnut sign, Hampton hump sign, Westermark
sign, and juxtaphrenic peak sign, and for CT the gloved finger
sign, CT halo sign, signet ring sign, comet tail sign, CT an-
giogram sign, crazy paving pattern, tree-in-bud sign, feeding
vessel sign, split pleura sign, and reversed halo sign.
Key words: X-ray computed tomography, X-ray thorax
Diagn Interv Radiol 2011; 17:1829
Signs in chest imaging 19 Volume 17 Issue 1
rior borders of the lateral costophrenic
angle conspicuous (8).
Continuous diaphragm sign
The continuous diaphragm sign oc-
curs as a result of continuation of me-
diastinal air accumulated at the lower
border of the heart with both hemidi-
aphragms (Fig. 4). It is useful in differ-
entiating pneumothorax from pneu-
momediastinum (7).
Air crescent (meniscus) sign
The air crescent (meniscus) sign is
the result of air accumulation between
a mass or nodule and normal lung pa-
renchyma (Fig. 5). It is most frequently
encountered in neutropenic patients
with aspergillosis. In invasive aspergil-
losis, nearly two weeks after the onset
of the infection, neutrophils increase
in number and separate necrotic tissue
from the normal lung parenchyma.
The separated area then fills with air,
resulting in the air crescent sign. In
Figure 1. ac. Air bronchogram sign. a. Chest X-ray of a patient who had
radiotherapy for breast cancer. Consolidation with air bronchograms (arrows) due
to radiation pneumonitis at the upper lobe of the right lung. b. Air bronchogram
sign on CT. c. Illustration of air bronchogram sign.
b a
b
a
Figure 2. a, b. Silhouette sign. a. Chest X-ray of a patient without any
complaints; the lesion obscures the right border of the heart (arrow). b. CT
image demonstrates a cystic lesion (pericardial cyst) (arrow).
c
Algn et al. 20 March 2011 Diagnostic and Interventional Radiology
Figure 3. a, b. Hilum overlay sign. a. Chest X-ray of a patient with hemoptysis demonstrating enlarged right hilus. Hilar vessels can be seen
inside the lesion, which shows that the lesion is not at the hilus (arrow). b. Lung CT, mass at the right upper lobe (arrows) and lymph nodes at
the right hilus.
b a
Figure 4. Deep sulcus sign and continuous diaphragm sign. Chest X-ray
obtained in the supine position from a patient with trauma history. Pleural
free air accumulating at the right costodiaphragmatic sinus and extending
to the hypochondrium is depicted (arrowhead). Mediastinal air neighboring
the lower border of the heart causes the continuous diaphragm sign by
combining the hemidiaphragms (arrow).
b
a
Figure 5. a, b. Air-crescent sign. a. Chest X-ray of a patient
with invasive aspergillosis; crescent-shaped air density around
the consolidation area is seen (arrow). b. Crescent.
Signs in chest imaging 21 Volume 17 Issue 1
an immunocompromised patient, this
sign is highly suggestive of invasive
aspergillosis. Other causes of the air
crescent sign are intracavitary fungus
ball (mycetoma), hydatid cyst with
bronchial involvement, hematoma,
abscess, necrotizing pneumonia, cystic
bronchiectasis filled with mucus plugs
and papillomatosis (2, 9). Saprophytic
colonization of aspergillus species
within the cavities previously formed
due to sarcoidosis and tuberculosis
causes intracavitary fungus ball forma-
tion. Air between the cavity wall and
the fungus ball can also cause the air
crescent sign. Normal host immunity
and the long period, often years, re-
quired for the formation of the ball
can aid in distinguishing this condi-
tion from invasive aspergillosis. The
balls movement with the movements
of the patient helps in differentiating
it from a malignant mass attached to
the wall (2).
Goldens sign
The goldens sign is encountered
when there is right upper lobe atelecta-
sis due to a centrally located mass. The
minor fissure migrates superiorly, and
a reversed S shape containing the
mass forms (Fig. 6). The superiorly dis-
placed, lateral and concave portion of
the S is formed by the minor fissure,
while the inferiorly and medially locat-
ed convex part is formed by the margin
of the mass. This sign is an important
clue indicating a central mass obstruct-
ing the bronchus. It can be seen in eve-
ry lobe, though it has been described
for the right upper lobe (10).
Cervicothoracic sign
The cervicothoracic sign is used to
describe the location of a lesion at the
inlet of the thoracic cavity. In this ana-
tomical space, the posterior portions of
the lung apices are located more supe-
Figure 6. a, b. Goldens (reverse S)
sign. a. Chest X-ray of a patient with
a centrally located mass. The reverse
S sign due to right upper lobe
atelectasis is clearly depicted. The
lateral portion of the S is formed
by the superiorly displaced minor
fissure and the medial portion by
the mass (arrows). b. Golden S.
b
a
Figure 7. a, b. Cervicothoracic
sign. a. Frontal radiograph of the
chest demonstrating a mass with
a distinct cranial border projecting
above the level of the clavicles,
supporting a posterior mediastinal
location (arrows). b. T1-weighted
coronal magnetic resonance
image of the same patient. The
left posterior mediastinal mass is a
biopsy-proven ganglioneuroma.
b a
Algn et al. 22 March 2011 Diagnostic and Interventional Radiology
riorly than the anterior portions (Fig.
7). For this reason, a lesion clearly vis-
ible above the clavicles on the frontal
view must lie posteriorly and be en-
tirely within the thorax. If the cranial
border of the lesion is obscured at or
below the level of the clavicles, it is lo-
cated at the anterior mediastinum (7).
The borders are not clearly delineated
because the lesion is far from the air-
filled lung and there are cervical soft
tissues at this level (7).
Luftsichel sign
The word Luftsichel in German
means air crescent. This sign is seen
in severe left upper lobe collapse. Due
to the lack of a minor fissure on the left
side, upper lobe collapse causes vertical
positioning and anterior and medial dis-
placement of the major fissure. The su-
perior segment of the left lower lobe mi-
grates superior and anteriorly between
the arch of the aorta and the atelectatic
lobe. The crescent-shaped radiolucency
around the aortic arch is called the Luft-
sichel sign (Fig. 8) (7, 11).
Scimitar sign
The scimitar sign indicates anomalous
venous return of the right inferior pul-
monary vein (total or segmental) directly
to the hepatic vein, portal vein or infe-
rior vena cava. A tubular-shaped opacity
extending towards the diaphragm along
the right side of the heart is seen (Fig. 9).
The abnormal pulmonary vein resem-
bles a Turkish sword called a pala. The
scimitar sign is associated with congeni-
tal hypogenetic lung syndrome (scimi-
tar syndrome) (12).
Doughnut sign
The doughnut sign occurs when me-
diastinal lymphadenomegaly occurs
behind the bronchus intermedius in
the subcarinal region (7, 12, 13). Lym-
phadenopathy is seen as lobulated
densities on lateral radiographs (Fig.
10) (12, 14).
Hampton hump sign
The Hampton hump sign occurs
within two days as a result of alveolar
wall necrosis accompanying alveolar
hemorrhage due to pulmonary infarct
(7). It is a wedge-shaped, pleura-based
consolidation with a rounded convex
apex directed towards the hilus (Fig.
11). This sign was first described by Au-
brey Otis Hampton (7). It is usually en-
countered at the lower lobes and heals
with scar formation.
Westermark sign
The Westermark sign describes a de-
crease of vascularization at the periph-
ery of the lungs due to mechanical ob-
struction or reflex vasoconstriction in
pulmonary embolism (oligemia). It was
first described by Neil Westermark (7).
An increase in translucency on frontal
radiographs is depicted (Fig. 12) (7).
Juxtaphrenic peak sign
The juxtaphrenic peak sign, which
occurs in upper lobe atelectasis, de-
scribes the triangular opacity project-
ing superiorly at the medial half of
the diaphragm (Fig. 13). It is most
commonly related to the presence of
an inferior accessory fissure (7). The
Figure 8. Luftsichel sign. A patient with a centrally located mass at the left lung. Frontal chest
radiograph demonstrates volume loss due to left upper lobe atelectasis and crescent-shaped
radiolucency around the aortic arch, formed by the upper segment of the left lower lobe (arrows).
Figure 9. a, b. Scimitar sign. a. Frontal radiograph of a patient with hypogenetic lung
syndrome. The abnormal inferior pulmonary vein is seen as a tubular opacity paralleling the
right border of the heart (arrows). b. Scimitar.
b a
Signs in chest imaging 23 Volume 17 Issue 1
Figure 10. a, b. Doughnut sign.
a. Lateral radiograph of the chest
demonstrates enlarged lymph nodes
at both hila and the subcarinal region.
The described pattern is formed by the
radiolucent area at the central portion
and by the surrounding opacities due
to the lymph nodes. b. Doughnut.
b
a
Figure 11. a, b. Hampton hump sign. a. Chest X-ray of a patient with pulmonary embolism showing a peripherally located, wedge-shaped
homogenous opacity consistent with the infarct area (arrow). b. Hump of a camel.
b a
Figure 12. Westermark sign. Frontal radiograph of a patient with pulmonary
embolism, showing increased radiolucency in the upper and middle zones of
the left lung due to decreased vascularization.
Figure 13. Juxtaphrenic peak sign. Frontal radiograph of a
patient with right upper lobe atelectasis (arrowheads), superior
displacement of the right diaphragm and a peak at the
middle (arrow).
Algn et al. 24 March 2011 Diagnostic and Interventional Radiology
mechanism is not known with cer-
tainty; according to one theory, the
negative pressure of upper lobe atel-
ectasis causes upward retraction of
the visceral pleura, and protrusion of
extrapleural fat into the recess of the
fissure is responsible (15). The juxta-
phrenic sign can also be seen in com-
bined right upper and middle lobe
volume loss or even with middle lobe
collapse only.
Computed tomography
CT halo sign
The CT halo sign represents an area
of ground-glass attenuation surround-
ing

a pulmonary nodule or mass on
CT images (Fig. 14). It is seen most
commonly in the early stage of inva-
sive aspergillosis in immunocompro-
mised patients. The CT halo sign has
also been described in patients with
eosinophilic pneumonia,

bronchioli-
tis obliterans organizing pneumonia
(BOOP), candidiasis, Wegener granu-
lomatosis, bronchoalveolar carcinoma,
and lymphoma (1619). Formation of
the halo sign varies according to the
disease. Alveolar hemorrhage in as-
pergillosis and/or tumor infiltration on
the bronchial walls in bronchoalveolar
carcinoma are considered the causes of
this sign (1619).
Figure 14. a, b. CT halo sign. a. Invasive aspergillosis in a patient with acute leukemia: CT image shows halo sign (arrows). b. Sunshine.
b
a
Figure 15. ac. Gloved finger sign. a, b. CT images of a patient with lung
cancer, showing bronchi filled with mucus. c. Gloved hand.
b a
c
Signs in chest imaging 25 Volume 17 Issue 1
Gloved finger sign
This sign is characterized by branch-
ing tubular

or finger-like soft tissue
densities (Fig. 15). This appearance
is formed by dilated bronchi filled
with mucus (mucoid

impaction). On
CT images, mucus-filled bronchi are
seen as Y- or V-shaped densities (20,
21). Any obstructing

lesion can lead
to distal bronchiectasis and mucoid
impaction. Benign and malignant
neoplasms, congenital

bronchial
atresia, broncholithiasis,

tuberculous
stricture, intralobar sequestration,
intrapulmonary

bronchogenic cyst,
and foreign body aspiration can cause
mucoid impaction of a bronchus. Al-
lergic bronchopulmonary aspergillo-
sis (ABPA),

asthma, and cystic fibrosis
can cause this sign without obstruc-
tion. In asthma and asthma with
ABPA, there is increased airway hy-
persensitivity and mucus

production.
Also, in APBA, the cause of bronchial
impaction is saprophytic prolifera-
tion of aspergillus organisms within
the dilated bronchi. In cystic fibrosis,
the cause of mucoid impaction is im-
paired ciliary

action and abnormally
thick secretions (20, 21).
Signet ring sign
Normally, the diameter of a bron-
chus is equal to the diameter of the
adjacent pulmonary artery (broncho-
arterial ratio = 1). The signet ring sign
occurs when the bronchoarterial ratio
is increased (7) (Fig. 16). This sign is
usually seen in patients with bron-
chiectasis or irreversible abnormal
bronchial dilatation (7). The signet
ring sign can be seen anywhere in the
lung. It is an adjunct finding that can
help in differentiating bronchiectasis
from other cystic lung lesions (22).
Accompanying findings such as peri-
bronchial thickening, lack of bronchi-
al tapering, and visualization of bron-
chi within 1 cm of the pleura are all
contributing findings confirming the
diagnosis (7).
Comet tail sign
The comet tail sign refers to curvilin-
ear opacities that extend

from a subp-
leural mass toward the hilum. It con-
sists of distortion of vessels

and bronchi
that lead to an adjacent area of rounded
atelectasis. This sign is a characteristic
feature of round atelectasis (Fig. 17).
Figure 16. a, b. Signet
ring sign. a. A patient with
bronchiectasis. Dilated
bronchus and the

adjacent
pulmonary artery are seen in
the left lower lobe (arrow).
b. Signet ring.
b
a
Figure 17. a, b. Comet tail sign. a. Prone CT image of a patient with tuberculosis pleuritis history. Subpleural atelectasis (arrow) and
bronchovascular structures extending toward the hilum (arrowheads) are seen. b. Comet.
b a
Algn et al. 26 March 2011 Diagnostic and Interventional Radiology
Adjacent pleural thickening is an es-
sential finding. There is volume loss
in the affected lobe. However, there
are two hypotheses regarding the for-
mation of the rounded atelectasis: an
underlying pleural effusion that causes
local

atelectasis in the adjacent lung
and a local pleuritis caused by irritants
such as asbestos, tuberculosis, non-
specific pleuritis or Dressler syndrome

(23). As in the other atelectasis types,
the homogeneous enhancement oc-
curs after the intravenous

administra-
tion of contrast material. The rounded
atelectasis is sometimes impossible to
differentiate from peripheral lung can-
cer. Biopsy is indicated

in cases that are
equivocal (23).
CT angiogram sign
The CT angiogram sign consists of
enhancing

pulmonary vessels in a ho-
mogeneous low-attenuating consoli-
dation

of lung parenchyma relative to
the chest wall musculature at the me-
diastinal window (Fig. 18). This sign
has been described in the

lobar form
of bronchoalveolar cell carcinoma (17,
24). Another important cause of the CT
angiogram sign is pneumonia. The low-
attenuating area has been considered
to be the result of mucus production
by tumor cells. The CT angiogram sign
has also been reported in pulmonary
edema, obstructive pneumonitis

due to
central lung tumors, lymphoma, and
metastasis from gastrointestinal

carci-
nomas (25, 26).
Crazy paving pattern
The crazy paving pattern consists
of scattered

or diffuse ground-glass
attenuation with superimposed inter-
lobular

septal thickening and intral-
obular lines (Fig. 19) (2729). It was
initially described in cases

of alveolar
proteinosis (30). In alveolar protei-
nosis,

the ground-glass attenuation

reflects the low-density intraalveolar
material (glycoprotein),

whereas the
superimposed reticular attenuation is
due to infiltration

of the interstitium
by inflammatory cells (29). This find-
ing can be caused by Pneumocystis

cari-
nii pneumonia, mucinous bronchoal-
veolar carcinoma, pulmonary

alveolar
proteinosis, sarcoidosis, nonspecific
interstitial

pneumonia, organizing
pneumonia, exogenous lipoid pneu-
monia,

adult respiratory distress syn-
drome, and pulmonary hemorrhage

syndromes (27, 28).
Figure 18. CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing
pulmonary vessels in a low-attenuating mass are seen.
Figure 19. a, b. Crazy paving pattern. a. Patient with situs inversus and Kartagener syndrome
showing diffuse ground-glass attenuation with superimposed interlobular

septal thickening and
intralobular lines in both lungs. The cause of diffuse parenchymal disease in this patient was
alveolar proteinosis. b. Paving stones.
b
a
Signs in chest imaging 27 Volume 17 Issue 1
Tree-in-bud sign
The tree-in-bud pattern is character-
ized by small centrilobular nodules
connected to multiple branching lin-
ear structures

of similar caliber origi-
nating from a single stalk (Fig. 20).
This pattern is a finding of small air-
ways disease. Initially, this sign was
described in cases with transbronchial

spread of Mycobacterium tuberculosis
(31). It has subsequently

been reported
as a manifestation of a variety of enti-
ties. These entities

include peripheral
airway diseases such as infection (bac-
terial,

fungal, viral, or parasitic), con-
genital disorders, idiopathic

disorders
(obliterative bronchiolitis, panbron-
chiolitis), aspiration

or inhalation of
foreign substances, immunological
disorders,

connective tissue disorders
and vascular diseases (particularly tu-
mor microembolisms) (7, 3234).
Feeding vessel sign
The feeding vessel sign consists of
a distinct vessel

leading directly to a
nodule or a mass (Fig. 21). This sign
has

been considered highly suggestive
of septic embolism and also frequent-
ly occurs in pulmonary metastasis
and arteriovenous fistula. It is rarely
seen in lung cancer and granuloma
(16, 35).
Split pleura sign
The split pleura sign is characterized
by thickened pleural layers separated
by fluid (Fig. 22). This sign is found
primarily in empyema, and it helps to
differentiate from abscess. It is also fre-
quently seen in hemothorax and talc
pleurodesis (20, 36).
Reversed halo sign
The reversed halo sign (atoll sign)
is defined as a focal round area of
ground-glass attenuation and sur-
rounding air-space consolidation of
crescent or ring shapes (37). Kim et al.
were the first to describe this particular
CT feature as the reversed halo sign.
Figure 20. a, b. Tree-in-bud pattern. a. Patient with tuberculosis: small centrilobular nodules connected to multiple branching linear structures

are seen. b. Tree-in-bud.
b
a
Figure 21. Feeding vessel sign. A patient with bronchial carcinoma.
Pulmonary artery

leading directly to the mass is seen.
Figure 22. Split pleura sign. A patient with empyema. Visceral
and parietal pleura are thickened and separated because of
fluid.
Algn et al. 28 March 2011 Diagnostic and Interventional Radiology
It is defined as a central ground glass
opacity surrounded by denser consoli-
dation shaped like a crescent (forming
more than three quarters of a circle) or
ring (forming a complete circle) that
is at least 2 mm in thickness (38, 39)
(Fig. 23). The reversed halo sign seen
on CT appears to be relatively specific
to a diagnosis of cryptogenic organiz-
ing pneumonia (38). It is also reported
in lymphomatoid granulomatosis, sar-
coidosis, pulmonary paracoccidioid-
omycosis and other pulmonary fungal
infections (3842). Voloudaki et al.
reported that the central ground glass
opacity corresponds histopathological-
ly to the area of alveolar septal inflam-
mation (inflammatory infiltrates in the
alveolar septum with macrophages,
lymphocytes, plasmatic cells and some
giant cells, with a relative preservation
of alveolar spaces) and cellular debris
and that the ring-shaped or crescen-
tic peripheral air-space consolidation
corresponds to the area of organizing
pneumonia within the alveolar ducts
(37, 41).
Acknowledgment
We gratefully acknowledge Michael
Armstrong and Aydn Kuran for their contri-
butions.
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